Palpation of Pulse for Cardiac Arrest

One of my personal goals is to make my life easier. Yes, that is easier said than done; particularly given my proclivity for working in the Emergency Department. The ED is not an easy place to work many times, particularly when faced with truly life-altering events like a pediatric cardiac arrest. While managing pediatric cardiac arrests is never easy (no matter how clinically skilled you are), the first task of determining whether the child actually does or does not have a pulse would seem to be the easiest. Sadly, it is not.

Phases of Pediatric Cardiac Arrest

The Back to Sleep program, Submersion awareness, and trauma prevention are example.

Also where being vigilant for “covert sickness“ can came in handy (hopefully the Morsels help you with this part).

No-Flow

This is the Arrest part (obviously).

We really need to limit the time spent in this phase!

Factors that are known to be associated with survival with good neurologic outcomes are:

Having the arrest be witnessed.

Obviously, this impacts the time for an AED to arrive, initiation of bystander CPR, etc.

Having the duration of CPR be short.

Having an initial rhythm that is shockable (much more rare occurrence in children).

Younger age.

Low-Flow

This begins when CPR begins.

The goal is to obtain Return of Spontaneous Circulation (ROSC) as well as maintain cerebral perfusion!

We know that the basics of CPR (quality Chest Compressions while allowing recoil of the chest wall and minimizing interruptions) are the most important aspects of the resuscitation.

Post-Arrest

After ROSC is obtained, the body experiences multiple stressors and potential injuries.

Post-Cardiac Arrest Syndrome

Brain Injury

Myocardial Dysfunction

Systemic ischemia/reperfusion response (similar to SEPSIS)

Palpation of Pulse is Not Easy

If getting out of the No-Flow phase is imperative, then it means that detecting the No-Flow phaseis important so that chest compressions can be started promptly.

Problem: We aren’t good at feeling pulses!

When medical providers were challenged to determine whether a pulse was present in patients (don’t worry, the patients were on ECMO):

Only 78% of doctors and nurses correctly determined presence or absence of a pulse.

14% of the time the falsely identified the presence of a pulse!

Therefore, 14% of the time when compressions should have been initiated, they would have been delayed.

Problem: We need more time… that the kid doesn’t have!

We are supposed to detect a pulse within 10 seconds…

The mean time for rescuers to determine a lack of a pulse was 30 seconds.

Interestingly, experienced doctors and nurses are quicker at deciding when a pulse is present, BUT they are not quick at deciding when a pulse is absent!!

Essentially, experience helps you to rule-out cardiac arrest, but not rule it in!

“Palpation of pulse by healthcare providers to diagnose cardiac arrest in infants and children is both time-wasteful and unreliable!” (Tibballs, 2010).

When Should You Start Chest Compressions?

It is advocated that the lay-public minimize the importance of palpation of pulse.

Lay-person rescuers have been advised to give chest compressions to a collapsed infant/child on the basis of observation of lack of movement, unresponsiveness and inadequate breathing.

While skilled professionals (like us) should determine whether there is a pulse, we should also recognize that every second counts and if you are uncertain after 9 seconds, err on the side of being conservative with overcalling a lack of pulse.

Essentially, I would rather be wrong by starting chest compressions when the child has a weak pulse that I have not appreciated rather than not starting compressions when they are needed.

So make your job easier… stop trying to be perfect and err on the side of being safe… if you aren’t sure there is a pulse after 9 seconds… on the 10th second initiate compressions!!

References

Sandroni C1, Nolan J; European Resuscitation Council. ERC 2010 guidelines for adult and pediatric resuscitation: summary of major changes. Minerva Anestesiol. 2011 Feb;77(2):220-6. PMID: 21368728. [PubMed] [Read by QxMD]
The new European Resuscitation Council (ERC) guidelines for cardiopulmonary resuscitation (CPR) published on October 18th, 2010, replace those published in 2005 and are based on the latest International Consensus on CPR Science with Treatment Recommendations (CoSTR). For both adult and pediatric resuscitation, the most important general changes include: the introduction of chest compression-only CPR in primary cardiac arrest as an option for resc […]

Sarti A1, Savron F, Ronfani L, Pelizzo G, Barbi E. Comparison of three sites to check the pulse and count heart rate in hypotensive infants. Paediatr Anaesth. 2006 Apr;16(4):394-8. PMID: 16618292. [PubMed] [Read by QxMD]
Current international guidelines state that heart rate counted at the brachial pulse must be absent or <60 b x min(-1) to diagnose cardiac arrest. Some data suggest that this site may not be the best to check cardiac activity. Hypotension is a likely real scenario of the need for chest compressions in infants. We compared the performance of three sites of pulse palpation (brachial, carotid, and femoral) for detecting and counting heartbeat in […]

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

2 Responses

I use ultrasound and hold the probe in the groin. Once a round of compressions is done I look at the ultrasound screen first – in a fraction of a second I know if there is pulsatile flow or not. If not, then I look at the rhythm. A little unconventional but goes faster than palpation, especially in low flow states. After all presence of pulsatile flow is what we are aiming for in cardiac arrest!